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Office of Health Care Quality

Bland Bryant Building Spring Grove Hospital Center 55 Wade Avenue


Catonsville, Maryland 21228 (410) 402-8100 Fax: (410) 402-8270
To:

Program Applicants Therapeutic Group Homes

From:

Office of Health Care Quality (OHCQ)


Mental Health Unit

Re:

Program Application (Revised: July 16, 2007)


Mental Hygiene Administration
Community Mental Health Services

Enclosed is the Application Packet for licensure for Therapeutic Group Homes under the Mental
Hygiene Administrations (MHA) Community Mental Health Program.
Included in this Application Packet are:
1. Application
a. Program Service Plan Requirements
b. Application Face Sheet
2. Program specific Regulations
Upon completion, application should then be submitted to the following:
1. Copy to:

The appropriate Core Service Agency (CSA)

2. Copy of the application and Business Plan to3


Ms. Audrey Chase & Marcia Anderson
Mental Hygiene Administration
Mitchell Building, Spring Grove Center
55 Wade Avenue
Catonsville, Maryland 21228
3. Copy to:

Mr. William Dorrill, Deputy Director


Residential and Community Programs
Community Mental Health Services Unit
Office of Health Care Quality
Bland Bryant Building, Spring Grove Center
55 Wade Ave, Catonsville, MD 21228

Office of Health Care Quality


Community Mental Health Program Application

Application for Therapeutic Group Homes will not be reviewed without first being
approved through The Single Point of Entry located within The Governors Office for
Children.

The Office of Health Care Qualitys Community Mental Health Unit in collaboration
with the Mental Hygiene Administration will review the application for regulatory
compliance.

Applicants should consult CSA regarding the completion of their application


The Mental Hygiene Administration will be reviewing the business plan
If you have any questions regarding this process, please contact Office of Health Care Qualitys
Community Mental Health Unit at 410-402-8100.

Website Information

Office Of Health Care Quality - Community Mental Health Unit (C-MHU)


o Telephone Number:
410-402-8060
Fax: 410-402-8270
http://www.dhmh.state.md.us/ohcq/index.html
Department of Health And Mental Hygiene(DHMH)
http://www.dhmh.state.md.us/
Code of Maryland Regulations (COMAR)
http://www.dsd.state.md.us/comar/
The Mental Hygiene Administration (MHA)
http://www.dhmh.state.md.us/mha/
Core Service Agency Directory
http://www.dhmh.state.md.us/mha/csa.htm
CJIS Central Repository
http://www.dpscs.state.md.us/publicservs/bgchecks.shtml

Office of Health Care Quality


Community Mental Health Program Application

Therapeutic Group Home (TGH)


Application Face Sheet

1. Business Name:

________________________________________________

2. Trade Name:

________________________________________________

3. Address:

________________________________________________
________________________________________________

4. Contact Name and Affiliation: _____________________________________________

5. Contact Number:

________________________________________________

6. Fax Number: ____________________________________________________

7. Email Address: __________________________________________________

8. Location of Proposed Program (If Different From Above):


______________________________________________
______________________________________________

9. Proposed TGH Capacity: ______________

10. Proposed Gender: __________________

Office of Health Care Quality


Community Mental Health Program Application

Attestation:
I, ________________________________________________ (AUTHORIZED AGENCY
REPRESENTATIVE), affirm that _______________________________________________
(NAME OF BUSINESS ORGANIZATION) shall comply with all applicable laws and
regulations concerning Medicaid and the establishment and operation of a community
mental health programs.

Please check all that apply:

Program/Individual/Corporation ______ has or ______ has not had any license or


approval revoked by the Department or other licensing agency in Maryland or any
other state;

Program/Individual/Corporation or entity associated with the program ______has


or ______ has not surrendered or defaulted on its license or approval for reasons
related to disciplinary action in Maryland or any other state;

Program/Individual/Corporation ______ does or ______does not have a corporate


officer who has served as a corporate officer for a corporation or entity that has had
a license revoked, or has surrendered or defaulted on its license or approval for
reasons related to disciplinary action within the previous 10 years.

Program/Individual/Corporation or entity associated with the program ______has


or ______ has not been sanctioned by MHA, a professional/credentialing body or
any other regulatory agency in the last 10 years.

SIGNATURE:

________________________________________________

DATE:

________________________________________________

Office of Health Care Quality


Community Mental Health Program Application

Therapeutic Group Home (TGH)


All applicants must comply with the provisions of both Code of Maryland Regulation (COMAR)
10.21.07(TGH) and COMAR .14.31.05, 14.31.06, and 14.31.07. The documents that must be
submitted to satisfy the application process are noted below for ease in reference and response.
1. Documentation of the applicants non-profit status
2. Proof that sufficient financial resources are available for the establishment and
operation of the residence
3. Identification of the owner of the property that is to be the TGH
4. Fire and health inspection reports of the proposed residence (not more than one year
old)
5. Evidence the program is registered with the Department of Assessment and Taxation
6. A narrative explanation of how compliance will be achieved with both 10.21.07 and
14.31.05, 14.31.06 and 14.31.07
7. Identification of the Psychiatrist, Clinical Coordinator and Certified Program
Administrator including a signed job description to identifies the hours on-site and job
responsibilities, resumes & verification of license.
8. Documentation that the TGH will collaborate with the CSA
9. Documentation that the site meets local zoning regarding size, land use, density, etc.
Including the results from a current lead and asbestos test.
10. All applicants who are applying to providing Group Home services or services to
minors must be registered with CJIS
(http://www.dpscs.state.md.us/publicservs/bgchecks.shtml) and show evidence that
background checks through the fingerprinting process has been completed for the
applicant, certified program administrator, clinical coordinator and all other direct care
staff
11. A Program Service Plan that includes:
Articles of Incorporation, bylaws, and member list
Documentation that at least 1/3 of the members of either the governing body or
an advisory committee includes representation of consumers, former consumers
or family members
The number of children to be served, their age groups and other relevant
characteristics
The goals, objectives and expected outcomes of the program
The plan for the provision of medical services, dental services, required
education, social and recreational services, nutritional services and mental
health treatment
12. A description of how linkage will occur with service providers and community
resources, including as applicable, written agreements with inpatient facilities and other
mental health providers
13. Staffing patterns and an organizational chart detailing lines of authority and
responsibility
14. The programs Policy and Procedure for the development of the assessment, safe
environment plan, ITP, ITP review and bi-weekly summaries
15. The programs policy for the implementation of individual, family and group therapy.
16. The programs policy and procedure for training of staff including curriculums used.
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